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Xenotransplantation, Nonhuman Death and Human Distress

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Xenotransplantation, Nonhuman Death and Human Distress 47 Have a Heart: Xenotransplantation, Nonhuman Death and Human Distress Tania Woods1 BRUNEL, THE UNIVERSITY OF WEST LONDON An increasing shortage of transplant donor organs currently results in an escalating number of preventable human deaths. Xenotransplantation. the use of animal organs for transplantation into humans, is now heralded as medicine's most viable answer to the urgent and insurmountable human organ scarcity. Although claimed to be a biomedical prerogative, xenotransplantation is a cultural phenomenon - a procedure engaging both the physical and symbolic manipulation of human and nonhuman bodies, thereby transforming corporeality, identity, and culture. Biomedi- cal and scientific discourses about xenografts have obscured issues related to nonhuman animals and also could be distressful to human organ recipients, revealing that the xenograft may not be widely embraced. Organ transplantation is one of medicine's most potent symbols. In the late 20th century, organ replacement surgery has been presented, both in the media and medical texts, as a miracle of modern medicine (Birke, 1996). The replacement of diseased vital organs with healthy cadaveric organs is now routine - a therapy that not only extends life, "but also improve(s) its quality ... [and] is not particularly expensive" (Nuffield Council on Bioethics (NCB), 1996, p. 2). For biomedicine. the continuing success of organ replacement technology is now hampered only by deficits in "natural" resources: organs available for transplantation. As each year passes, the shortfall in organ supply increases, resulting in unnecessary patient morbidity and mortality (Caplan, 1992; Calne, 1993; NCB, 1996). Remaining tenaciously unresponsive to alternative procurement policies, health education strategies [Bulletin of Medical Ethics (BME), 1991 ; Caplan, 1992], or changes in the diagnosis of death (Ohnuki-Tiemey, 1994; Singer, 1994), organ scarcity now constitutes one of medicine's fastest growing problems (Concar, 1994). The answer to the human organ shortage is now seen to lie in the resurrection of the xenograft, or trans-species transplantation. The use of animal products and parts iss already routine in human medicine. As yet unfamiliar, and more ambitious, is the proposed transplantation of whole organs, such as the heart, from healthy transgenic animals into humans with end-stage organ failure. 48 The first xenografts involved transplanting monkey, goat, sheep, dog, and pig organs into humans and took place in Europe at the turn of the century. The physicians of the time were unaware that "discordant xenotransplantation," be- tween such distantly related species, would cause the human immune system to mount a much fiercer rejection than "concordant xenotransplantation" between more closely related species. "Hyperacute rejection" is the fierce immune response whereby xenoreactive antibodies disrupt the endothelial cells of the foreign organ, causing the blood to clot in the vessels. Concurrently, "complement proteins" attack the transplanted organ by punching holes in cell membranes. Subject to thiss combined onslaught, the graft becomes black, swollen, clotted, and is rapidly destroyed. All early attempts at xenotransplantation failed and the procedure was aban- doned until the early 1960's, when the source animal chosen became the nonhuman primate. Nonhuman primates were chosen based on the premise that the closer the phylogenetic similarity between the "donor" and recipient, the less severe the rejection process might be. Clinical trials confirmed that kidney, heart, and lung xenografts were capable of functioning within the human body. The rejection process proved to be qualitatively similar, but quantitatively more severe, as the genetic disparity between the donor and recipient widened. So, for baboon-to-human xenografts (longest survival 98 days) the clinical rejection, although much improved from non-primate grafts, was severe and repetitive. Chimpanzee-to-human xenografts (longest survival nine months), however, showed survival rates comparable to allografts of the same period. From an immunological perspective, primate grafts were proving to be a viable option, whereas bioethical objections, raised both on behalf of the early experimental recipients and the animals, made it "abundantly clear that the killing of monkeys to save human lives was too emotive ever to be a practical solution" (Stark, 1996, p. 169). After a century of sporadic xenotransplantation, totalling around 35 clinical trials [British Union for the Abolition of Vivisection (BUAV),1995a], biomedicine has now turned to the cheap and plentiful pig as a source of organs and to "transgenesis" as a way of overcoming the problem of hyperacute rejection. Transgenesis involves the transfer of human genetic material into the pig. The cells ; of "transgenic pigs" then carry a protective human "armour" of "complement regulating proteins" - the proteins that naturally coat the human cells and inhibit the activation of the toxic complement protein that causes rejection. The pharma- ceutical industry sees transgenesis as a breakthrough for xenografting and has invested heavily in this area (both in the United States and England). Using breeding herds of genetically modified pigs, trials involving transgenic pig-to- 49 simian xenografts have already taken place (longest survival 60 days) and trials with humans are considered imminent (Nowak, 1994). Xenotransplantation is an auspicious contemporary theme, resurrected against the historical and efficacious backdrop of allotransplantation. Xenografting encap- sulates the powerful transformation of science and new genetic engineering technology into a surgery focused on the postponement of human death. These cogent images combine to herald the xenograft as a timely, germane and optimistic example of a rapidly evolving "high technology medicine" (Robinson, 1994), a medicine within which animal organs become a realistic means of restoring human health, and animal "sacrifice," a means of scientific progress. There are, however, more voices to be heard within this unfolding medical drama.2 Despite its biomedical efficacy, transplantation cannot be assumed to be personally and culturally unproblematic. Although all illness is associated with questions of human ontology, organ transplantation is a process in which disputes over the nature of the body, life, death, and personhood become particularly acute (Joralemon, 1995; Sharp, 1995). Transplantation transgresses the received di- chotomies of life and death, self and non-self, and human and animal (Ohnuki- Tierney, 1994; Lock, 1995), manipulating and blurring the boundaries of the human body and thereby, human identity and culture. Despite the biomedical prerogative, the issues that xenotransplantation raises cannot, therefore, be re- solved "simply on medical grounds" (Wilkinson, 1996, p. 28), for they touch upon too many aspects of human and nonhuman life. The Xenotransplantation Imperative In Japan, public debate concerning the diagnoses of death and their implications for organ procurement and transplantation has been informed, participatory, and influential. Conversely, in North America and parts of Europe, there has been almost no public discussion. In the West, the development of the artificial heart (Fox & Swazey, 1992), kidney transplantation (Plough, 1986) and advancing technological medicine, have come about largely without ethical debate and legislation (Kimbrell, 1993). Moreover, these medical advances may owe more to the technological imperative, personal and institutional power and profit, than to the postulated success of the procedures for reducing morbidity in patients or populations (Preston, 1994; Stark, 1997). Xenotransplantation's technological imperative and its massive corporate financial backing (BUAV, 1995b ; P. Martin, 1995) raise concerns that medical experimentation will go ahead before full debate has taken place (Fullbrooke & Wilkinson, 1996). This threatens to leave potential 50 human organ recipients and nonhuman animals mute in the face of the power of "science" and the success of biomedical procedures. For, "the powerful objective of saving [human] life ... has traditionally tended to overwhelm critical questions s about the means ... and the consequences of the process" (Robinson, 1994, p. 6). This article addresses the "muted" (Ardener, 1975a; 1975b) discourses - the voices that compete for credibility alongside the "articulate" metalanguages of science and medicine. By venerating the experiences of transplant patients, the fears of potential xenograft recipients, and the claims made on behalf of "donor" animals, it is clear that the xenograft may not be widely embraced (Mohacsi, Blumer, Quine & Thompson, 1995) - inside or outside of biomedicine. Science or Fiction: Which Voices are Credible? In the unfolding representation of the xenograft, one British story has been prominent. "The organ factory of the future" (Concar, 1994), featuring Astrid, the "pig with the human heart," was first published in the New Scientist. Subsequently it was used as part of an information package, created in the spring of 1995, by the British Nuffield Council on Bioethics Working Party on the Ethics of Xenografts.1 This article was the only overview of xenografts dispatched to prospective contributors, and as such has served as a crucial narrative that has helped British understanding of xenotransplantation. The following paragraph forms the intro- duction to this article: At a secret location
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